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A 79-year-old man underwent stent implantation into a severely calcified proximal left anterior descending coronary lesion (Figure 1) in December 2012 followed by restenting in March 2014 to treat in-stent restenosis (Figure 2), both without full balloon expansion. Optical coherence tomography (OCT) documented thick, peri-stent napkin-ring calcium. He was admitted for recurrent unstable angina in April 2014. After initial treatment with excimer laser coronary angioplasty (ELCA; 1.4 mm, Spectranetics Corporation, Colorado Springs, Colorado) using saline injection, fluence of 60 mJ/mm2, and frequency of 80 Hz, a balloon was fully expanded. OCT showed fracturing of peri-stent calcium and good stent expansion (Figure 3). This approach has been reported in the ELLEMENT (Excimer Laser LEsion Modification to Expand Non-dilatable sTents) registry (1); in the current case, we used OCT to document the mechanism behind this approach.

Calcium appeared as radio-opaque bands on both sides of the lumen (A, A') and circumferential (B, B'). A stent (2.75 × 22 mm) was post-dilated by a noncompliant balloon (3.0 × 9 mm, 22 atm) with a final 28% diameter stenosis (DS). Boxed areas in A and B are shown magnified in A′ and B′, respectively.

Matched OCT slices and longitudinal reconstruction showed a pre-excimer laser coronary angioplasty (ELCA) MSA of 2.26 mm2, no change post-ELCA (white arrow), but fracturing of the thinnest part of the calcium after balloon post-dilation with a noncompliant balloon (3.5 × 9 mm, 22 atm) resulting in good stent expansion (MSA = 6.34 mm2) and a final DS of 10%. Abbreviations as in Figure 2.

Acknowledgments

The authors thank Fernando A. Sosa, MS, from St. Jude Medical for his assistance in image collection.

Footnotes

Dr. Maehara has received grant support from Boston Scientific; is a consultant for Boston Scientific and ACIST Medical Systems; and has received speaker’s fees from St. Jude Medical. Dr. Moses is a consultant for Boston Scientific. Dr. Mintz has received grant support and is a consultant for Boston Scientific and Volcano Corporation. Dr. Shlofmitz is on the speakers bureaus of CSI, Janssen Pharmaceuticals, and St. Jude Medical. Drs. Yin and Mezzafonte have reported that they have no relationships relevant to the contents of this paper to disclose.